anticipatory guidance four months education/four month visit.pdf · anticipatory guidance four...

Anticipatory Guidance Four Months

FEEDINGS: Sometime between 4-8 months, babies will start to show a real interest in foods. In years past, nearly all babies at this age were eating a variety of foods. You may feel pressure from friends or family to start foods. There is no need to add foods into your baby’s diet during the first 6 months. The only food baby really needs is breast milk and/or infant formula. If your baby has been on a low-iron formula for some reason, it is important now to change to a formula with iron; your baby may become anemic. Babies that have been breast-fed now need iron. They may have used their iron stores from birth. Breast milk does not have enough iron for your baby’s growth. Most babies at 6 months will do well with a few simple foods, mashed bananas, rice cereal, or applesauce. If you five baby apple juice between feedings, remember to mix using ½ juice and ½ water. Too much apple juice can cause loose bowel movements. DO NOT give your baby whole, low-fat, or non fat milk or milk products. Your baby’s stomach is not yet ready for those foods. Stay with the milk based formula of iron. REMEMBER; DO NOT FEED HONEY TO YOUR BABY UNTIL 12 MONTHS OF AGE. SAFETY: At this age, the baby’s first thought with any new object is: Can I eat it? They will put everything into his/her mouth, so be very careful that their world is free from the little objects that could be dangerous if put into their mouth: buttons, hard candies, peanuts, small toys, you name it. It is up to you to make your baby’s world safe to play in and enjoy. Your baby will soon start crawling. Put up some kind of barrier at stairways when your baby does start to crawl, or other areas that he/she could be hurt. Have you turned down the temperature of your hot water heater? Not only will the water be safer for your child, it will also save you money on your electric bill. Keep this number readily available: Poison Control Center— 1-800-492-2414 or 410-706-7701. SLEEPING POSITION: Recent study has shown that babies should not sleep on their stomachs. Babies who sleep this way have a greater risk of sudden infant death syndrome (SIDS). Babies should be put to sleep on their back or sides. If placed on their side, place a cushion so they cannot roll onto his/her stomach. COLDS: Most babies begin to get colds and runny noses at this age. The protection that was transferred to baby from their mother has now worn off. Most colds need no treatment. Medicines may have side effects and it is generally best to avoid using unnecessary

medicines for infants. It is normal for a child to run a fever the first few days of a cold. If your baby has a fever on the fourth day, there is a possibility that the cold has turned into a secondary infection. Your baby may have an ear, sinus, or bronchial infection. You may want to call your baby’s doctor. DO NOT use over-the-counter cold medicines without your doctor’s advice. For a cough, a cool-mist vaporizer in your child’s room may allow your baby to sleep better. To remove clear mucus from your baby’s nose, use a nasal aspirator. Salt water nose drops and bulb suction may help loosen mucus and will sooth the mucus membrane and make it easier to breathe. TEETHING: The average for baby’s first tooth to break through is six months, but he/she may have pain as the tooth is cutting through the deeper layers of the gums. Teething may cause a slight change in bowel habits, a slight nasal discharge, and/or fussiness and crankiness. The common teething creams and gels will help when first applied and give only temporary relief. For teething pain you may use liquid Tempra or Tylenol, which may be repeated every 4 hours for discomfort. Teething does not cause fever. If your baby is fussy or grouchy and has a fever, contact your doctor. IMMUNIZATIONS: Your baby now should have received his/her secondary set of vaccines (shots). Remember to ask your baby’s doctor to update your record book. Be sure to report any unusual reaction after the shots to your baby’s doctor. Always bring your child’s shot record with you.

Social Development•Is becoming more independent—may be moreinterested in playing alone than being held

•Imitates hand and facial gestures•Crawls around to look for parents•Crawls to you w hen name is called•Likes to play “peek-a-boo”•Turns handful of pages books and magazines•Likes to play sound games•Waves “bye-bye”•Understands simple directions

12 monthsPhysical Development

•Begins to change from a crawl to a totteringwalk wi th legs wide apart

•Feeds self finger foods•May begin to use a spoon•Squats

Speech Development•Uses “Dada” and “Mama” to refer tospeci fic persons

•May have a vocabulary of 3 to 10 "real" words•Adds gestures to own body language

Social Development•Loves an audience•Scribbles wi th crayons•Has more variety in play•Exhibits stronger likes and dislikes•Flirts with and kisses self in mirror•Plays with dol ls and stuffed animals•Points to objects in books and identi fies them•Understands simple words and phrases like “Come to Daddy.”


•Stands and walks alone•Uses a spoon to feed sel f•Picks up things from a walking position

Speech Development•Uses simple words and phrases•Says some words spoken by parents

Speech Development•Laughs, squeals, and babbles•Coos and gurgles with joy•Says “ooh” and “ahh”

Social Development•Loves to p lay with own feet•Sees colors rather than black and white•Fusses when wanting to be picked up and held•Can tell the di fference in family members•Reaches out hands and arms to play•Smiles

7monthsPhysical Development

•Sits up by self for a short time•Holds toys and feeds sel f pieces of food•Stands when held, takes some of the weighton own legs

•Reaches for objects, transfers them fromhand to hand

•Begins teething, which may disturb sleepSpeech Development

•Combines vowel sounds•Imitates sounds•Responds to “no” and own name•Uses body language to ini tiate interaction

Social Development•Plays alone•Plays longer w ith people and toys•Enjoys other children•Grows more responsive to sound•Withdraws from strangers, clings to fami liarcaregivers

10monthsPhysical Development

•Crawls using different craw ling styles•Crawls over objects•May stand leaning against an object•Picks up small objects with thumb and fingers

Speech Development•Says “no,” “bye-bye,” “dada,” and “mama”•Uses voice to get attention

Birth—2 monthsPhysical Development

•Barely li fts head to clear surface•Keeps hands tightly fisted

Speech Development•Coos and makes grunting sounds•Babbles

Social Development•Sleeps a lot•Cries a lot•May have erratic sleeping and feeding patterns•Quiets in response to parent’s face and voice


•Lifts head while lying on stomach•Has smooth motions•Relaxes fist, unfolds fingers•Waves hands and kicks feet w hen on back

Speech Development•Coos and gurgles increasingly, especially whentalked to

•Cries differently for different needsSocial Development

•Begins to smile, show excitement and distress•Turns to famil iar voices•Quiets when held•Enjoys being tickled•Maintains brief eye contact while being fed•May suck thumb or finger to quiet self


•Can see across a room•Sits erect when supported•Rolls over from tummy to back•Reaches for toys•Holds objects•Reaches for feet and br ings them to mouth•Turns head to local ized sounds•Follows people wi th eyes

Babies need much more than food andwater to grow up healthy. Among otherthings, they need love, understanding,

guidance, and security. They need you to helpthem learn about their world, develop skil ls,and adjust to their ever-changing needs.

Playing an active role in your baby’s developmentcan be exciting, enriching and rewarding. Youwill notice changes in appearance, behavior andlanguage almost daily, and soon you’ll realizeyour baby's successful development dependsgreatly on your participation in the process.

As you observe your baby’s growth, keep inmind that no two children are exactly alike.While there are certain "typical" stages of growth,your baby may develop at a different pace thananother baby. Additionally, your baby maydevelop quickly in one area, but not as quicklyin another.

If you believe your child is having difficultyin a particular developmental area, don’t panic.Many challenges related to development canbe helped through early intervention—a systemof services offered to enhance a child’s potentialfor growth and development before the childreaches school age.

The information contained in this brochureis not intended to be comprehensive. It may,however, be useful as a general guide to whatyour baby may be doing at a particular age.

Keep this information in a safe and accessibleplace so that you can refer to it easily—perhapsin a scrapbook, baby book or wherever youkeep family records. If you have questions, callyour local Infants and Toddlers Program.

Growth and Developmental Milestones

MARYL AND STATE DEPARTMENT OF EDUCATIONDivision of Special Education/

Early Intervention ServicesMaryland Infants and Toddlers Program

200 West Baltimore Street, 9th FloorBaltimore, MD 21201Phone: 410-767-0261

Toll free: 1-800-535-0182Fax: 410-333-2661

TDD: 410-333-0731

MARYLAND STATE DEPARTMENT OF EDUCATION

Social Development•Likes to listen to music and dance to rhythms•Says “no” and refuses food•Is more aware of surroundings•Is growing more independent•Is very active


•Runs stiffly•Uses whole arm when playing ball•Feeds self, eats w ith a spoon, tries a fork•Takes off shoes, hat, mittens•Loves to lug, tug, dump, push, and pul l•Goes up and down stairs wi thout help

Speech Development•Knows names of objects•Uses personal pronouns

Social Development•Loves to explore•Often refuses foods


•Undresses self (large items such as pajamas)•Begins to kick•Handles a cup w ell•Takes things apart and puts them together again

Speech Development•Speaks more clearly•Replaces “baby” language with short sentences•Likes to talk to sel f•Repeats words others say•Combines words and actions

Social Development•Identifies wi th surroundings•Enjoys helping Mommy and Daddy•May enjoy cleaning up after p laying•Is very active•May have periodic temper tantrums•May point to named body parts


•Swings and climbs•Jumps in place•Walks backward•Peddles tricycle

Speech Development•Talks in short sentences, uses plurals•Sings short songs•Language is understood by othersbesides parents

•Says own name•Increasingly uses “no”•Announces fears and dislikes

Social Development•Feeds self wel l w ith spoon and fork•Drinks from a straw•Strings large beads•Dresses self well•Begins to identi fy gender roles•Explores environment outside of home

Tips for Parents• Babies learn to talk when they hear others. Talk,

sing, and read to your baby.

• Babies like physical contact. Touch, rock andhold your baby.

• Babies sense tension. Responds to your baby’scries quickly and tender ly. Be sensitive whentalking to your baby and to others in his presence.

• Nature stimulates babies’ interest in the outsideenvi ronment. Take frequent outdoor w alks withyour baby. The fresh ai r is also helpful.

• Provide toys that are appropr iate for yourchild’s age and development. M obiles, colorfulboxes, push/pul l toys, large blocks, big balls andmusical instruments are all good ideas.

• Handle your baby w ith care. Babies and youngchildren should NEVER be shaken!

DevelopmentalMILESTONES

Growth

A GUIDETO DEVELOPMENT

IN YOUNG CHILDRENBIRTH TO AGE THREE

MARYL AND STATE BOARD OF EDUCATIONEdward L . Root, President

Jo Ann T. Bel l, Vice PresidentPhil ip S. BenzilDunbar Brooks

Calvin D. DisneyClarence A. Haw kins

Walter S. L evinKarabelle Pizzigati

Maria C. Torres-QueralJohn L . Wisthoff

Christopher J. Caniglia

Nancy S. GrasmickState Super in tendent of Schools

Carol Ann BaglinAssistant State Super intendent, Division

of Special Education/Ear ly In tervention Services

The Maryland St ate Department of Education does not discr iminate onthe basis of race, color, sex, age, national origin, religion, or disabilityin matters affecting employment or in providing access to programs.For inquiries related to departmental policy, p lease contact t he EquityAssurance and Compliance Branch at 410-767-0246 V oice, 410-333-8165 Fax, or 410-333-6442 TDD. ✦ This document was developed andproduced by the Division of Special Education/Early InterventionServices, IDEA, Part C, grant #H181A020124, funded by th e U.S.Department of Education, Office of Special Education and Rehabilita-tive Services. The views expressed herein do not necessarily reflectthe views of the U.S. Department of Education or any other federalagency and should not be regarded as such. The information iscopyright free. Readers are encouraged to copy and share it, but pleasecredit the Division of Special Education/Early Intervention Services,Maryland St ate Department of Education. ✦ In accordance w ith theAmerican w ith Disabilities Act (ADA) this document is available inalternative formats, upon request. Contact the Division of SpecialEducation/Early Intervention Services, Maryland State Department ofEducation, 410-767-0249 Voice, 410-333-8165 Fax, 410-333-0731 TDD.

4/04

Robert L . Ehrl ich, Jr.Governor

DANGER: The Hazards of Baby Walkers

A baby walker can pose a hazard to your child’s well-being. How? Emergency room physicians in Delaware Valley hospitals have noted an increase in the number of small children being injured in baby walker falls during the past few months. Robert S. Walter, M.D. attending pediatrician in Emergency Services at the Institute, says that the incidence of baby walker falls heightens during the winter and early spring months because children are indoors more. In the cases he is aware of, parents could not intervene in time to stop the accidents from happening. In three incidents, a four-month-old baby toppled off a porch in a walker and sustained a depressed skull fracture; a 10-month-old boy suffered a concussion after he fell down a flight of steps in a walker, and a none-month-old girl sustained a traumatic brain injury when she slid in her walker off the deck of her home. Dr. Walter urges parents to decrease the changes of baby walker accidents by seriously considering NOT USING walkers at all. He indicated in his own investigations, most people use walkers to keep children quiet, occupied and happy and help them learn to walk. The pediatrician counters that walkers do not promote walking and, in some cases, may impede walking skills and promote bad walking habits, especially in children who have special needs. Dr. Walter reports that most walker injuries occur to children who spend one hour or more daily in the contraptions. Citing a report from the American Medical Association on the use of infant walkers, Walter says that

over a million are sold annually. Over 70 percent of ALL infants born in the U.S. in a year will use a walker, usually between the ages of five and twelve months. Of these infants, 30 to 40 percent have some type of walker mishap. The types of injuries that result most frequently from walker accidents range from contusions, abrasions and lacerations to more serious head trauma, fractures and burns. Most injuries happen when the child falls down stairs (approximately one-half of these falls occur while stairwell gates are in use), tips over, pulls objects on top of him or gets his fingers caught in various entrapments around the home. Dr. Walter notes that if parents must use a walker, limit it to one-half hour a day on the ground floor, away from stairs, with direct supervision. He reminds parents that even the edge of carpets can sometimes trip the baby. “This type of accident can happen to any child,” relates Dr. Walter. “I’ve worked in inner city areas and suburban areas and I’ve seen walker accidents in both. I’d advise parents to think twice before purchasing a walker for their child.” For more information about child and walker safety, contact the Alfred I. DuPont Institute children’s hospital at 1-800-829-KIDS.

Introducing Solid Foods to Your Baby

You may begin introducing solid foods between now and the six month visit. Do this if your child shows that he is ready. There is no rush! Starting after the six month visit is fine, too. • Begin with infant rice cereal once or twice a day. Mix two teaspoons of dry cereal

with breast milk, formula or water until it becomes a thin soup. Use a baby spoon and place the cereal about half way back on your baby’s tongue. As he or she learns to handle cereal this way, gradually increase its thickness. Also increase the amount fed to two tablespoons. Ripe bananas can be offered next, followed by other fruits, vegetables, and meat.

• Introduce one new food at a time. Feed your infant the new food a few times over three or four days before starting a new food to make sure your infant doesn’t have an allergic reaction. Vomiting, diarrhea or skin rash are signs that a food doesn’t agree with your baby. Do not serve the food again for a few months if this happens.

• Talk, sing, make faces and touch your infant during meals. Meals should be a fun time for you and your baby.

• Be relaxed about the first few weeks of introducing solids. It is not important how much cereal or fruit your baby eats. Your infant needs to adjust to the tastes, textures and a new way of eating. The majority of your baby’s nutritional needs are still being met by formula or breast milk for the next few months.

• Honey should not be given to your baby until he or she is one year old.

When children begin crawling, or eating table foods, parents must be aware of the dangers and risks of choking. Older infants and children less than 5 years ofage can easily choke on food and small objects.

Choking occurs when food or small objects get caught in the throat and blockthe airway. This prevents oxygen from getting to the lungs and the brain. When the brain goes without oxygen for more than 4 minutes, brain damage or evendeath may occur. Many children die from choking each year. Most children whochoke to death are younger than 5 years of age. Two thirds of choking victims areinfants younger than 1 year of age.

Balloons, balls, marbles, pieces of toys, and foods cause the most chokingdeaths.

The American Academy of Pediatrics believes that parents and other care-givers can prevent choking. The Academy offers the following choking preventionand first aid information for parents and caregivers of infants and children.

Dangerous foodsDo not feed children younger than 4 years of age any round, firm food unless it is chopped completely. Round, firm foods are common choking dangers. Wheninfants and young children do not grind or chew their food well, they may attemptto swallow it whole. The following foods can be choking hazards:• Hot dogs• Nuts and seeds• Chunks of meat or cheese• Whole grapes• Hard, gooey, or sticky candy• Popcorn• Chunks of peanut butter• Raw vegetables• Raisins• Chewing gum

Dangerous household itemsKeep the following household items away from infants and children:• Latex balloons• Coins• Marbles• Toys with small parts• Toys that can be compressed to fit entirely into a child’s mouth• Small balls • Pen or marker caps• Small button-type batteries• Medicine syringes

What you can do to prevent choking• Learn cardiopulmonary resuscitation (CPR) (basic life support).• Be aware that balloons pose a choking risk to children of any age.• Keep the above foods from children until 4 years of age. • Insist that children eat at the table, or at least while sitting down. They should

never run, walk, play, or lie down with food in their mouths.• Cut food for infants and young children into pieces no larger than one-half inch

and teach them to chew their food well.• Supervise mealtime for infants and young children. • Be aware of older children’s actions. Many choking incidents occur when

older brothers or sisters give dangerous foods, toys, or small objects to ayounger child.

• Avoid toys with small parts and keep other small household items out of reach of infants and young children.

• Follow the age recommendations on toy packages. Age guidelines reflect the safety of a toy based on any possible choking hazard as well as the child’sphysical and mental abilities at various ages.

• Check under furniture and between cushions for small items that childrencould find and put in their mouths.

• Do not let infants and young children play with coins.

First aid for the child who is chokingMake a point to learn the instructions on the reverse side of this brochure. Postthe chart in your home. However, these instructions should not take the place of an approved class in basic first aid, CPR, or emergency prevention. Contact your local American Red Cross office or the American Heart Association to findout about classes offered in your area. Most of the classes teach basic first aid,CPR, and emergency prevention along with what to do for a choking infant orchild. Your pediatrician also can help you understand these steps and talk to you about the importance of supervising mealtime and identifying dangerousfoods and objects.

The information contained in this publication should not be used as a substitute for the medical care and advice of your pediatrician. There may be variations in treatment that your pediatrician may recommendbased on individual facts and circumstances.

Choking Prevention and First Aid for Infants and Children

From your doctor

The American Academy of Pediatrics is an organization of 57,000 primary care pediatricians, pediatric medical subspecialists, and pediatric surgical specialists dedicated to the health, safety, and well-being of infants, children, adolescents, and young adults.

American Academy of Pediatrics PO Box 747 Elk Grove Village, IL 60009-0747 Web site — http://www.aap.org

Copyright ©1998, Revised 09/01American Academy of Pediatrics

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